Blog: BSR Indian Rheumatology Exchange Fellowship

Dr Maliha Shaikh and Dr Priyanka Chandratre share their experience from the 2016 BSR Indian Rheumatology Exchange Fellowship at the P.D Hinduja Hospital, Mumbai, India. Read their individual blogs below.

Front row (left to right): Dr Sakir Ahmed, Dr Avinash Jain, Prof Amita Aggarwal, Dr Maliha Shaikh (UK Exchange Fellow), Prof Ramnath Misra, Prof Sudhir Sinha, Shobhita Katiyar, Shruti Bhattacharya
Back row (left to right): Dr Vikas Gupta, Dr Abishek Zanwar, Dr Sandeep Kansurkar, Dr Suvrat Arya, Dr Rutviz Mistry, Dr Pravin Jain

Blog: Dr Maliha Shaikh, Rheumatology Registrar, North East and 

Central London Deanery

I am very grateful to have been one of two trainees awarded an inaugural Exchange Fellowship by the BSR and Indian Rheumatology Association. This Fellowship has been set up as an opportunity for trainees to visit a centre abroad and experience the different challenges and opportunities in practising rheumatology in a different country. This is the first year this Fellowship has been offered, with the exchange fellows from India expected to visit the UK later this year.
There were two host centres in India, based in Lucknow and Mumbai (Hinduja Hospital). I visited the Sanjay Gandhi Postgraduate Institute in Lucknow under the mentorship of Professor Amita Aggarwal, President of the Indian Rheumatology Association. Lucknow is in the north-east of India, close to the border with Nepal and south of the Himalayan foothills. SGPGI was established in 1983 as a governmental initiative for a tertiary referral centre and teaching hospital. It is located on the outskirts of the city, approximately 10 miles from the city centre. The campus is one of the largest medical campuses in India, spanning around 550 acres and combines the hospital, research facilities and accommodation for staff and guests.  Being a tertiary centre, the hospital does not offer services in every specialty. There is no Accident and Emergency Department. Instead there is a focus on providing specialist medicine and surgery that is not readily available elsewhere. All patients who are seen must have a referral letter. As well as providing specialist care, the institute has a focus on superspecialty teaching, post graduate medical training and research. The hospital has a catchment area of around 300miles, with patients often crossing the border from Nepal.

Above: SGPGI campus (photo courtesy of Dr Sakir Ahmed)

India has a population of approximately 1.2 billion people and accordingly the health care requirements are huge. Additionally there is a divide between the rich and poor with the associated challenges of working in a resource poor environment. Government hospitals provide basic care but ultimately the level of care is determined by patients’ ability to fund their investigations and treatment. SGPGI is a government initiative and all investigations and treatment are partially subsidised by the government. While is the care is not entirely free as in some of the medical college hospitals, the fees are affordable by most. All patients need to open an account with the hospital and deposit money into this to cover their healthcare costs. In circumstances where a patient is unable to meet the costs of treatment, there are funds available from the hospital that can be arranged by the responsible consultant. The necessary focus on patients’ income and the need to tailor treatment and investigations to what they are realistically able to afford brought home to me how fortunate we are to have our NHS.

Rheumatology at SGPGI is in fact offered through the Department of Clinical Immunology. Professor Aggarwal has a subspecialty interest in juvenile rheumatic disease. She also has a cohort of patients with immunodeficiencies who are managed by the department. The clinical department consists of 4 full time consultants and 11 registrars. The consultants also oversee the basic science lab and provide supervision for PhD students and post doctoral researchers. The department has a dedicated ward with 20 dedicated inpatient beds. These are used for admissions from clinic as well as for day cases for infusions as there is no day unit.

SGPGI introduced a computer based system a few years ago to manage their patient records. This allows investigations to be requested online and results are available electronically. Discharge summaries are also electronic which is extremely helpful in maintaining records of care that are easily accessible. Medical notes for both inpatient and outpatients are still paper based, as in most hospitals in the UK. 

One of the biggest differences with the UK was the sheer volume of patients, particularly in outpatients. There are approximately 500 new patients and 2500 follow up patients seen every month. The outpatient clinic is structured so that each day tends to have a particular focus, such as SLE, vasculitis, rheumatoid arthritis or systemic sclerosis. In outpatients, the consultation and plan is recorded in a book that the patient takes away and can use for follow up locally until their next appointment. Monitoring is often limited and patients often present very late in their disease course. Patients have to take much more responsibility in their long term disease management as there is no primary care set up. They are told about the monitoring tests that are required and will often arrange these themselves and bring in their results for review.

There are also differences in the treatments given. For example, very little anti-TNF is used as it is expensive, which limits its use. Etanercept is the anti-TNF most often used. Intravenous prostaglandin is not generally available and many systemic sclerosis patients go away during the winter which is short lived. Certain drugs are also not available such as anakinra and endothelin receptor antagonists. Rituximab is the most common biologic used as it is affordable. 

While this is a general rheumatology department, there is a large cohort of SLE patients who often have very severe disease. I also had the opportunity to see Takayasu’s arteritis  which we see rarely in the UK but there is a large cohort of patients managed at SGPGI which was interesting.

Rheunatology in India is a relatively new specialty and training varies across the country from 2 year fellowships to 3 year DM programmes. Following euivalent, trainees complete a 3 year MD programme in. Specialist training in rheumatology can be undertaken after 3 years (post  Foundation Year 1) basic General Medicine training (MD). There is a postgraduate training programme offered SGPGI which was started in 1993. This was the first rheumatology training programme in India and the intake has increased over the years. At present, there are 11 registrars: 3 third years, and 4 in each of the first and second years. All three years are spent at SGPGI. There is a structured teaching schedule every day from 8-9 am. The registrars present at this regularly with case discussion, seminars and journal club. There is also an immunology-pathology combined MDT every month to review histology, mostly renal and skin biopsies.  Registrars have exams every semester and a final exit exam at the end of the third year, with written and clinical parts.

I also had opportunities to explore the city of Lucknow. Like many places in India, it has a rich cultural heritage with different influences evident. There is Mughal architecture such as the Bara Imambara, alongside Hindu temples as well as evidence of British and European influences. Lucknow is famous for its food, in particular the kebabs and biryani and this was also a wonderful experience. I was overwhelmed by the warmth and hospitality that I experienced during my stay.  I learnt later that Lucknow is renowned throughout India for its old world charm and ‘tehzeeb’, or refined, polite culture and hospitality which is a consequence of the Nawabs of the area who prized and cultivated this. 

I thoroughly enjoyed my visit to Lucknow, during which I had a wonderful time and have taken away a lot from it. I have developed professional relationships as well as friendships and the experiences and memories of my trip will stay with me. I would like to thank Professor Amita Aggarwal for her help in organising the logistics of my trip and for ensuring that everything went smoothly. I would also like to thank the whole Department of Clinical Immunology for making me feel so welcome and in particular, Dr Latika Gupta, Dr Sakir Ahmed, Dr Avinash Jain and Dr Vikas Gupta for all their help. I am extremely grateful to the BSR and the Indian Rheumatology Association for initiating this fantastic scheme and for providing me with such a valuable opportunity. I have gained a lot from this unique experience and I would thoroughly recommend it to future

Blog: Dr Priyanka Chandratre, Rheumatology Medical Trainee, West Midlands

I was delighted to be given the opportunity to visit the Rheumatology department at PD Hinduja Hospital, Mumbai under the mentorship of Dr C Balakrishnan. Hinduja Hospital Trust is a tertiary 300 beds medical and research Centre.  Although largely privately funded, there are subsidised charges for those with low paying capacity and approximately 25% of beds are earmarked for concessional rates. This was the first ever BSR led British trainee visit to an Indian Hospital. After a 14-hour flight I arrived in the sweltering November heat of Mumbai to be greeted by Dr Girish Kakde and Dr Romi Shah (registrars in Rheumatology) at the airport. 

The first day started at 8am with outpatient clinic which typically lasts all day.  A consultant and one registrar generally see approximately 50 patients during the day. The cases are a mix of new and follow-up. As the healthcare system in India does not have a primary to secondary care referral system, patients can self-refer or choose to see a physician of their choice based upon recommendations and physician’s performance rating. The postgraduate Rheumatology training in India consists of a year of internship followed by a three-year residency in general medicine and then a three-year specialty training leading to a Diploma of the National Board or Doctorate of Medicine. At the end of the specialty training physicians are free to practice Rheumatology in a variety of settings, including government funded or private hospitals as well as community based private clinics. 

Patients present with a mixture of soft tissue, auto inflammatory and autoimmune joint, vasculitis and connective tissue diseases.  Presentation is often delayed due to patient awareness, patients’ belief in the trial of Ayurveda or homeopathic medications prior to seeking ‘western’ drugs, lack of recognition amongst general physicians as well as uncertainty as to where to refer. A lot of the patients seen in the outpatient clinics were from remote areas where there is a paucity of practicing rheumatologists. Therefore the disease is often severe at presentation. Investigations are often already done prior to first consultation as the patient may have consulted a general physician in the community. Patients are under no obligation to get the investigations done at Hinduja, which due to its set up may be more expensive than other community based pathology and radiology Centres. The patients carry their own medical records which comprises of any previous outpatient consultations, in-patients admission discharge summaries as well as investigations. Hinduja maintains its own paper-based records. There are no universal electronic laboratory or radiological portals, as I assume the sheer number and mixture of private and government funded investigation Centres proves a challenge to make records centralised and interconnected between the various healthcare Centres. 

Treatment of autoimmune rheumatic diseases is generally consistent with international guidelines, although modifications have been made to suit the patient population and environment. For example, majority of patients with Rheumatoid Arthritis are on combination (three or four) DMARD therapy, which has been shown to almost as effective as biological drugs.  This is done particularly for patients who are unable to afford the cost of biologics, even if biosimilars are used as a substitute for the reference drug. The dose and administration intervals are often modified to suit the patients’ affordability. For example, infliximab biosimilar may be given at 3mg/kg instead of 5 mg/kg for RA and the dose interval is generally decided by the response to treatment.  Patients may receive biologics when they have a flare of their disease rather than regularly.  Infusions can be done either on the wards (categorized as general or deluxe, charges being higher in the latter) at Hinduja hospital or in community based local clinics or hospitals, according to patient choice.  Blood monitoring for DMARDs are generally only done prior to next appointment which can be every 6 to 12 months routinely. There are no provisions for in-house blood monitoring and no formal shared cared agreement between community-based general physicians and the rheumatologists. DMARDs are prescribed by the rheumatologist until the next appointment. However there are also no restrictions on physicians other than rheumatologists (generalists and specialists) to prescribe these if needed.  

Treatment efficacy and adverse effects are often confounded by homeopathic medications which may contain unknown amounts of steroid. Approximately 13% of patients with autoimmune rheumatic diseases also have concurrent tuberculosis and other infectious diseases (dengue, Chikungunya) therefore treatment with steroids, synthetic and biological DMARDs pose a considerable challenge that the Rheumatologists here face almost daily. Many times patients may be admitted locally for treatment of infections and the lack of communication between other HCPs and rheumatologists means that DMARDs or biologics may not necessarily be withheld during such episodes.  

Half way through the two-week exchange program, I attended the 32nd Indian Rheumatology Association Conference (IRACON) in Kochi, Kerala from 25 - 27 November. The theme for this year’s congress was “Indian Rheumatology: Complex needs, integrated solutions”. The conference was well attended by delegates from over twenty countries. The first day of the conference started with ‘Year in review: best papers in vasculitis and gout’. I thoroughly enjoyed the symposium on spondyloarthritis, HLA B27 and beyond, non-radiographic Spondyloarthritis and whether it is actually ankylosing spondylitis (Prof A Malviya, India) as well as novel treatments such as secukinumab (Dr H Nigil, Canada).  As always it was a pleasure to see familiar faces such as Dr Maya Buch presenting the predictors of response to anti TNF inhibitors and Prof Ian McInnes discussing the role of small molecules in the pathogenesis of RA. The conference was a fantastic opportunity to learn the advances as well as differences in clinical practice worldwide, network with colleagues and explore potentials for collaborative work and just enjoy the company of like-minded people.  

The first evening also saw the inauguration of the conference, attended by the governor of Kerala followed by a spectacular cultural performance showcasing the traditional dances (Kathakali and Kuchipudi) and martial art (Kalaripayattu) of Kerala.  We were looked after incredibly well with plenty of food and drinks not just throughout the evening but also the entire duration of the conference. 

I had another week to enjoy the hospitality of the team at Hinduja upon my return from the IRACON congress. There were a large number of interesting clinical cases due to late presentation and enhanced autoimmune disease severity in the large population of Indian ethnicity.  Some cases which I saw in the short time span of two weeks include Takayasu Arteritis, IgG4 disease, GPA with subglottic stenosis and severe SLE (abdominal pain, proximal weakness, hepatosplenomegaly, pancytopenia, dysphagia, skin pigmentation, cardiac tamponade, pericardial effusion, alopecia, pedal oedema, oral ulcers and oesophageal candidiasis). I am fortunate to have had the exposure to such interesting rheumatological cases during my short visit.  Dr Balakrishnan suggested a longer time span if possible, with the integration of a short clinical research project to suit both parties. This will of course need developing prior to the visit.  I would thoroughly recommend this fellowship to all rheumatology trainees, for the experience of complex cases and seeing a different approach to practicing medicine.  The entire experience was enjoyable and an eye opener in more ways than one. 

  Find out more information about the BSR Indian Rheumatology Exchange Fellowship